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After studies revealed significant problems with colonoscopies at private clinics — including incomplete procedures, missed cancers and patients being charged for access — Ontario’s cancer agency and the body that regulates doctors are taking steps to address shortcomings.

Critics say problems persist in spite of improvements and the province needs to do a lot more to protect patients.

“We are not done,” says Dr. Danielle Martin, chair of Canadian Doctors for Medicare.

Martin, who is also a family physician at Women’s College Hospital, says that when she tells patients about the studies, most choose to avoid private clinics.

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“When I counsel my patients about colon cancer screening, I explain to them that research shows that colon cancer is more likely to be missed with a colonoscopy done outside hospital. Given that information, most people prefer to wait for an appointment in a hospital setting,” she says.

“How can we ensure that we are offering Ontarians the highest standard of care? What is being done to address concerns about quality?” Martin asks.

An article published Thursday in Healthydebate. ca, an online magazine about health issues in Ontario, says much has been done in recent years to improve quality:

“Five years ago, researchers in Ontario raised concerns about access and quality in privately owned clinics that performed colonoscopy, suggesting that the quality in these clinics was significantly below the standard of care in public hospitals…. In the last five years, quality in private colonoscopy clinics appears to have improved.”

Cancer Care Ontario, the provincial agency that co-ordinates cancer services, is taking steps to monitor quality at some of these clinics. Clinics have also recently become regulated by the College of Physicians and Surgeons of Ontario.

Colonoscopies are among the many services that are increasingly being moved out of hospitals and into privately-owned but publicly-funded clinics, where it is argued they can provide faster, better and cheaper care. There are now more than 50 endoscopy clinics in Ontario providing colonoscopies, both for-profit and not-for-profit.

About one-quarter of all colonoscopies in Ontario are performed outside a hospital and the Liberal government wants to move more services like colonoscopies out of hospitals and into not-for-profit private clinics.

Because the sector has been rapidly growing, researchers, including some at CCO, wanted to take a closer look at them. In 2007, studies began being published revealing significant shortcomings.

One study in the journal Gastroenterology showed colonoscopies done in private settings in Ontario were not as thorough as those done in academic hospitals. It revealed 13 per cent of colonoscopies done in Ontario were not completed, meaning the scope didn’t make it all the way to the cecum, or the beginning of the large intestine. According to the study, the leading risk factor for an incomplete procedure was having the colonoscopy performed in a private clinic.

Research also suggested there were more missed cancers in private clinics than in hospitals.

“Colonoscopy practice in office settings may be suboptimal,” researchers wrote.

Another study published earlier this year in the Canadian Journal of Gastroenterology found that private colonoscopy clinics were more likely to screen low-risk patients more frequently than required.

Earlier this year, CCO started a pilot project that involved collecting information on quality measures from 32 clinics. It recently embarked on phase two of that pilot and is providing funding to nine of those clinics to participate in its colon cancer screening program. In return, the clinics receive funding to help cover overhead costs.

“The point that we would like to make is, yes, there was evidence of issues in terms of quality, but now we have a way forward and we are moving forward in Ontario, led by the work at Cancer Care Ontario,” says Dr. Linda Rabeneck, vice president of prevention and cancer control at the agency.

Rabeneck co-authored some of the studies showing the shortcomings.

“I am very confident that now not only are we able to measure quality but we are able to take action where we need to really raise the bar across the entire sector,” she added, explaining that CCO plans to develop a quality assurance program for clinics.

Still, some clinics have refused to participate.

“At the current time, participation is strictly voluntary,” Rabeneck says, indicating that greater oversight of the clinics is an evolving process. “We are upping the bar on the quality across the sector.”

Dr. Michael Gould is the clinical lead of CCO’s colon-cancer screening program and also president of the Vaughan Endoscopy Clinic, a private clinic. He says the public should have full confidence in the private clinics:

“My confidence in the clinic setting is such that I had my own colonoscopy in one. There have been significant efforts to date to ensure that clinics are performing safe, quality procedures in non-hospital ambulatory environments.”

Gould is also working with the CPSO, which in 2010 began inspecting out-of-hospital premises such as endoscopy clinics. Under new legislation the College was given two years to complete inspections on some 250 premises that also include cosmetic surgery, pain and cataract clinics. Its first report on these inspections comes out Monday.

It was through such an inspection that the CPSO discovered that equipment at an Ottawa endoscopy clinic was not being appropriately cleaned. As a result, some 6,800 of the clinics patients were told they had a small risk of contracting hepatitis B, C and HIV and were advised to get tested.

The CPSO then ordered the doctor who ran the clinic, Dr. Christiane Farazli, to stop performing the procedures.

Martin says that another big problem with private clinics is that some charge patients for services not covered by OHIP, often as a condition of getting access to OHIP-covered colonoscopies. That’s tantamount to extra-billing, Marin charges, noting the practice is illegal.

She was co-author of a study published last year in the Canadian Journal of Gastroenterology that suggested 31.7 per cent of patients in private clinics were being charged to access the services. For example, they could be charged to see a dietician for nutrition counselling and many viewed the charge as mandatory.

“My concern is that many of these colonoscopy clinics continue to charge patients for uninsured services as a condition of accessing the insured colonoscopy. They charge for a mandatory consultation with a dietician, or a cleaning fee, or for valet parking, or whatever,” she says adding that the fees are usually around $500.

Though the health ministry is on record as saying the practice is illegal, it doesn’t appear to have the capacity to police it, Martin says.

“CCO should not be channelling public funds to clinics charging illegal user fees,” she says. “They seem to be expressing a hope that this will occur less often, but they are not committing to withdraw from partnerships that engage in this kind of activity. Why not?”

Rabeneck hopes that funding from the CCO to cover some of a clinic’s overhead costs will be an incentive to stop charging fees.

Martin’s study also found that 10 per cent of private-clinic patients said the doctors who delivered the care at the private clinics were the same ones who initially referred them there from hospital, suggesting a conflict of interest.

“This is the time for the province to put its stake in the ground on issues like this,” Martin says. “If it believes that moving things from hospital to community should not be done in a way that undermines the equity in the system, then this is exactly the time when they have to draw a line in the sand about it.”

Healthydebate.ca is a website focused on health care in Ontario, edited by health-care professionals and members of the health community who work within the system.

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